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The Importance of Mobility

Poor Mobility and Injury Risk

I’m fascinated by the human body, its unlimited potential and resiliency to injury. However, one of the main factors undermining resiliency is a lack of mobility. Mobility refers to a joint’s (ankle, knee, hip etc.) ability to access its entire available range of motion without restriction or compensation from local or regional muscles and/or joints.

Take the hip, for example. Optimal hip extension is around 15°-20°. That means your leg should be able to move behind your body 15°-20° without movement of other joints. In contrast, sub-optimal mobility would be anything less than that. Signs of less than optimal mobility would be excessive arching of the lower back, rotation or side-bending to the side of the moving leg or failure to keep the leg completely straight when walking.

In a perfect world, each joint in our body should be able to move throughout its entire range of motion. Optimal mobility allows the muscles crossing these joints to function with improved efficiency and strength. When mobility of a joint is lost, the human body compensates by forcing other nearby joints to move more. The human body will get the desired movement completed even if it sacrifices integrity and quality. Restoring mobility to the affected joint will (more times than not!) improve symptoms such as pain, decreased strength and stability!

Revisiting the earlier example, the lower back is the next area in the body chain that is forced to compensate for the loss of hip extension. It does so by extending itself, enabling more motion to occur at the lower lumbar vertebrae than normal. Over time, due to the accumulation of micro-trauma to the local tissues, the lumbar spine can begin to become painful. This sets in motion a vicious cycle of compensatory joint and muscle reactions to maintain function and equilibrium. I liken it to the old phrase, “Robbing Peter to pay Paul.” The body “robs” the lumbar vertebrae of some of its motion (in actuality, forcing it to do MORE) to “pay” the hip for its lack of extension. This can be acceptable in the short-term, but is not a long-lasting solution. Especially if that solution involves pain-free movement! Restoring proper hip extension mobility is the key to reducing excessive stress on the lower back, breaking that cycle of compensation and getting out of pain!

The same principles apply for most, if not all, of the joints of the human body. That’s why the painful region may not be the location of the solution. For every joint that doesn’t move enough, there is a joint nearby that is moving too much. Too little or too much movement creates dysfunctional muscles, perpetuating the cycle! Finding a skilled movement professional who understands these concepts is crucial to getting out of pain.

As the “Human Performance Mechanic,” its my job to recognize asymmetries, address them and provide long-lasting and permanent solutions to pain. In the current example, this may mean targeting the hip muscles with manual therapy to loosen them up prior to mobilizing the hip joint. I tell this analogy to my clients to help them understand the complex relationship between mobility and compensations that arise contributing to pain:

“If we’re talking about relating our body to corporate infrastructure, the joint is ‘mid-level management’ and the muscles that cross said joint are ‘low-level employees’. The joint provides information to the muscles in a top-down fashion, leaving the muscles crossing the joint to react to what the ‘orders’ are. ‘Low-level employees’ reactions can include increasing tone, giving the feeling of ‘tightness’ and ‘cramping’ commonly reported with reduced mobility. Both the joint and the muscle are underneath the ‘CEO’, the brain. The brain not only receives feedback from the muscles and joints, but is capable of giving ‘orders’ to either, showing its place at the top of the proverbial corporate infrastructure. When there is a lack of mobility in one joint, the ‘CEO’ will look to see what other ‘mid-level management’ is available to accomplish the objective. This command is given without consideration of the long-term consequences.”

Return to long-lasting pain-free movement requires addressing the entirety of the “corporate infrastructure”. If a significant change is required, it has to come from the top-down! That’s why its important to strive for optimal joint mobility because it keeps the entire “infrastructure” in homeostasis. Without adequate mobility, the ‘low-level employees’ get conflicting orders (think increased tone compared to normal, further reducing joint mobility) and the ‘CEO’ has to deal with the fall-out!

This is the reason why I do a full-body mobility screen with everyone that sees me (except for post-operative management). The screen serves two purposes – I can look at the area in pain and determine if mobility is restricted as well as pre-emptively addressing areas lacking mobility that may be causing stress but are not yet causing pain. From the full-body mobility screen, I get a ‘big picture’ view of the client’s movement resulting in a more comprehensive and systematic treatment plan. With a full hour one-on-one with my clients, I have enough time to address both local and regional mobility deficits and get them pain-free faster than traditional care.

In summary, a lack of mobility is a problem that can manifest itself as pain in other regions. Its not uncommon to have knee pain as a result of a lack of motion at the ankle, hip or back. A full, comprehensive assessment and intervention plan to address a lack of mobility will improve resiliency, reduce or prevent future injuries and get you back to experiencing the joy of pain-free movement!… Read the rest

Blood Flow Restriction – What You Need to Know

The Importance of Strength and Muscle Mass Strength and muscle mass are extremely important to longevity and sports performance. Studies have shown that the amount of fat-free mass (which includes your muscles as well as other non-fat structures like bone) is a predictor of all-cause morbidity (disease) and mortality (death!). Increasing and/or maintaining a high level of muscle tissue is beneficial for overall health. Higher levels of muscle mass also closely correlate to higher levels of strength and athletic performance, highlighting the importance of muscle mass for both health and performance purposes.

Traditional resistance-training guidelines for gaining strength and muscle mass involve lifting weights greater than 70% of the 1-rep maximum. For example, if an individual’s maximum bench press is 100 lbs, in order to improve strength and muscle mass of the arms and chest, these guidelines would suggest lifting at 70 lbs or greater during workouts.

Blood Flow Restriction Training Blood flow restriction (BFR) training is a new therapy tool that has been proven safe and beneficial for optimizing muscle mass and strength. BFR involves application of a cuff-like tourniquet placed over the closest part of the arm or leg (see pictures below).

The tourniquet is inflated prior to the start of treatment, reducing the ability of blood to be pumped back to your heart from the occluded limb. This creates temporary increases in oxygen demand for the muscles for the duration of the treatment. The increased demand for oxygen means that muscles have to work harder than they normally would in order to produce a muscle contraction. This stresses the muscle at weights where it normally would not be stimulated (between 20-35% of the 1-repetition maximum, or 20-35 pounds in the bench press example). Most people see benefits without using any weights at all!

The machine is for all intents and purposes, a computer that constantly monitors the amount of pressure it applies to the body, keeping it the same the entire time of the treatment (something other tools that do BFR do not do!). The pressure applied to the leg by the machine is illustrated by the number “199” in the image above. The number will vary based on the size of the limb. In my case, the number is higher due to my thigh size. If the same measurement was taken on my arm, the value would be much lower. How this all happens is through the portal on the front of the machine (the circled area) that serves as the connection between the machine and the cuff allowing air to be pressurized.

Using Blood Flow Restriction Training While the cuff is being inflated, individuals should feel some tightness around the arm/thigh as the machine calibrates the specific pressures needed for the treatment. After a short calibration period, the therapist will configure the appropriate settings based on the goals of treatment.

Anyone using BFR should never feel pain, numbness or tingling during or after exercise. BFR does create an environment where the muscles have to work hard, so that “muscle burn” is expected. In fact, that’s how the muscles are getting bigger and stronger! The above picture is my “BFR face” during the last set of 10 pound bicep curls! The “muscle burn” is real!

Typical amount of sets and repetitions for an exercise with BFR include a first set of 30 repetitions (to create that “muscle burn” effect) followed by 3 sets of 15 repetitions (total of 75 repetitions for the entire exercise). Each inter-set rest period is about 30 seconds. The machine keeps the pressure consistent throughout the duration of the rest periods, preventing any of the blood from escaping the muscle. This can be slightly uncomfortable.

Following completion of the exercise, the therapist will deflate the cuff.

Let me tell you – it feels amazing afterwards! I’ve had many people tell me that it feels like a great massage to the arm or leg and that they feel that the arm/leg feels “looser” and that it had a “good workout.” These are what I like to call the rewards for working hard! Not to mention, the muscle mass and strength gains to come!

Some people may experience some soreness 24-48 hours after the exercise. This is normal and if it occurs, will likely be similar to what it feels after exercising a new muscle for the first time in awhile. I must say though, that in my experience with this training tool, less than half of people report being sore at all!

Who Can Use BFR? I will touch upon these individually in greater detail in upcoming posts, but here are some examples of when BFR can help:

  • Post-surgery (day 3-day 14) – when weightbearing or actively moving the muscle is difficult, use of BFR with passive range of motion can help in preservation of muscle mass and strength and facilitate a quicker return to function and sport
  • Post-surgery (day 14+) – active range of motion with the surgical arm/leg can promote muscle mass and strength increases of the surgical region as well as other muscles located before and after the application of the cuff
  • Elderly – strength training in a safe manner to improve function and reduce fall risk
  • Athletes – in-season maintenance of muscle mass and strength
  • General Fitness – adding BFR to heavy load training can ensure muscle fatigue and help improve strength and muscle mass outcomes; it can also be used as a de-load week to give joints a break while continuing to promote increases in muscle mass and strength
  • Improving Aerobic Endurance – BFR has been shown to improve aerobic endurance capacity at lower intensities than ever thought possible in shorter amounts of time compared to traditional low intensity (for example – jogging) training
  • Improving Bone Density – there is evidence suggesting that BFR can stimulate bone growth in a walking or resistance-training program
  • Individuals with Neuromuscular Conditions – because there is minimal to no muscle damage occurring with BFR, populations with conditions such as Inclusion Body Myositis
Read the rest

What Does Physical Therapy Mean?

Physical therapy may mean something different to you than me. I elaborated on this briefly in my last blog post. Physical therapy is my career, my passion and my intellectual escape. I live and breathe physical therapy and am extremely fortunate to have found a calling in a career that enables me to explore many different opportunities in education, research and of course, patient care.

How do others define ‘physical therapy?’

I did a quick Google search for “physical therapy” and “physical therapist.”

According to:

TheBalance.com – These health professionals use a variety of techniques, called modalities, to restore function, improve mobility, relieve pain and prevent or limit permanent physical disabilities in their patients. Wikipedia.com – Physical therapy (PT), mostly known as Physiotherapy, is one of the allied health professions that, by using mechanical force and movements [Bio-mechanics or Kinesiology], Manual therapy, exercise therapy, and electrotherapy, remediates impairments and promotes mobility and function. Physical therapy is used to improve a patient’s quality of life through examination, diagnosis, prognosis, and physical intervention. It is performed by physical therapists (known as physiotherapists in many countries). American Physical Therapy Association – Physical therapists can teach patients how to prevent or manage their condition so that they will achieve long-term health benefits. PTs examine each individual and develop a plan, using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability. In addition, PTs work with individuals to prevent the loss of mobility before it occurs by developing fitness- and wellness-oriented programs for healthier and more active lifestyles. You get the point.

What do all of these definitions have in common? Improving function! The disconnect I have seen in this “sick care system” is that function is arbitrary! In fact, in the eyes of insurance companies, 85% return to function is a success.

Can you imagine: only receive 85% pain relief from back pain? 85% plantar fasciitis relief? 85% of the range of motion of your joints?

Don’t even get me talking about running! That’s classified as a “participation restriction,” meaning the insurance company views running as leisurely activity. In my experience in this “sick care system,” once someone gets to running, they’re already on their way out. What happened to getting people better and keeping them better?

What if you are a runner and your goal was to get back to a 6:00 minute mile pace after rehabilitating from knee pain? Wouldn’t you have apprehensions about returning to a sport you love knowing that you were discharged at 85%? How would that make you feel?

As a profession that prides itself on helping individuals return to function (and supposedly pain-free!), we’ve been doing a lousy job succumbing to the present day circumstances of care.

How can this be remedied?

Be inside a model that VALUES your 100% return to function.

The cash-based model affords me the ability to be 100% patient-focused geared towards facilitating 100% complete return to the activities you love to do, whatever they are. I am able to restore function, eliminate pain and encourage performance. This is Physical Therapy at its best. That’s what Physical Therapy means to me.… Read the rest

Are You a Honda or a Ferrari?

If you considered yourself a car model – what car model would you be? Would you envision yourself as a Honda or something more like a Ferrari?

Now keep that thought….

I can’t tell you the discrepancies I have heard when I’ve asked the simple question, “what do you do in physical therapy?” Such a simple question should produce simple answers, right? Well, I’ve been told that Physical Therapy is where I:

· Get massages to help reduce my pain

· Get heat/ice on my region of pain

· Get electrical stimulation to my muscles to help reduce my pain

· Get ultrasound to help with my healing and reduce my pain

· Do some exercises to help with my pain

· Talk about posture to help with my pain

· Work on my “weak” muscles

Listen – I am not here to take a stab at my profession’s vast inadequacies in providing excellent care and promulgating fear-mongering with the general public (that’s another blog!). In fact, I view it as a huge opportunity to make a significant impact on changing the perception of physical therapy to anyone I am fortunate enough to treat! This is why I have decided to leave the traditional insurance-based model in favor of cash-based services as The Human Performance Mechanic. Let me explain why so you have a better understanding from my perspective.

The structure of the current healthcare system works as a barrier to the motivated and determined physical therapist, directly influencing quality of care. In a clinic that takes all forms of insurance, reimbursements to the provider for services rendered are not enough to cover the costs of overhead.

What’s the strategy then? Well, take more patients per hour! In-network clinics that take insurance are quite literally forced to take 2-4 patients per hour to keep the doors open. This is a huge problem!

What does this mean for the client looking to alleviate his/her pain? It means receiving sub-optimal care, regardless of how skilled the physical therapist is at his/her job. You (the patient) will be placed on electrical stimulation and ultrasound machines, ice and heat, as well as inevitably working with a physical therapy aide for the majority of your program. Yes, the majority of time spent in therapy will be spent by yourself or with a physical therapy aide. This is a problem. You come to therapy to get better, yet spend 45 minutes of the hour you’re there without the direct supervision of a physical therapist. You want to know why you’re put on those machines? They are reimbursed very well by your insurance company. The evidence of their effectiveness in relieving your pain is minimal to non-existent, especially with the ultrasound machines, but physical therapists within these clinics are basically “forced” to use them as a tool for time management. Yes, you heard it right, time management.

Physical therapists quite literally can’t afford to spend more than 15-20 minutes with you every session. As much as he/she wants to help you get rid of your pain, they are constrained by falling reimbursements and corporate/office policies and incentives to maximize “productivity” (which means seeing MORE patients per hour for increased pay). Unfortunately, this is the beginning of a negative feedback loop that influences your physical (think “pain”) and financial (think “co-pay”) well-being.

Typically with an in-network clinic, you will be told that your condition, whatever it may be, will take anywhere from 6-8 weeks at 2-3 visits per week. This is what I like to call “the volume threshold” of in-network clinics. It’s a double entendre. The easiest surface definition is that the clinics want to get you in as frequently as possible to maximize the potential reimbursements from your insurance. This is to maintain the actual financial health of the facility. The “volume threshold” also serves to ensure that you as the patient, receive adequate amount of cumulative time with a physical therapist to ensure positive progression of your condition.

Now hear me out…if you’re going to physical therapy 2-3x per week for 6-8 weeks and expect to see the physical therapist for specific progressions to your program, this amounts to about 3-6 hours total of one-on-one care over 24-32 sessions.

Consider your co-pay and what it is on a per visit basis. Now consider what the constraints are of the physical therapists working within these models. Is this a truly healing environment suitable for getting you better and keeping you better? If your co-pay is $30, you are paying at minimum $720 for a physical therapist to address your issue over 24 sessions. This includes use of ultrasound and electrical stimulation machines, ice and heat packs and time working with an aide – all things that may or may not actively contribute to alleviating your pain! This isn’t even addressing the time component (possibly up to 8 weeks in a traditional plan of care)!

I circle back to the original question I posed at the beginning of this blog – “If you were a car, would you consider yourself a Honda or a Ferrari?”

Hondas can be taken to pretty much any local neighborhood mechanic. They’re relatively common vehicles far outnumbering the amount of Ferraris on the streets, so the local mechanics can handle these vehicles when they’ve got an operational issue. They’re trained to specialize in the mundane and average. The maintenance would be low cost and easily available! Perks for choosing the Honda!

On the other hand, if you had a Ferrari (and maybe you do!), would you take it to just any local mechanic to fix the operational problem? Or would you take it to someone who specializes in Ferraris?

What would you pay to know that your car is receiving the best possible care to keep it in top condition?

Now, consider this – a treatment session where you spend the entirety of your hour session with a physical therapist. Increased one-on-one time with the patient facilitates a great healing environment for … Read the rest

Biggest Lesson Learned in 2017

So let me preface this first blog post by saying get used to pictures of my dogs in my posts and around the site. Since this is my site, my thoughts, I’ve decided I want dogs and thus, there.will.be.DOGS!

As one of my dogs Charlotte (aka Charmu) is so eloquently tell-asking me, I actually did learn a ton of stuff in 2017. In fact, 2017 was one of the most accomplished years in recent recollection. I graduated with academic honors from Columbia University, moved into a great east side Manhattan apartment, treated full-time for 6 months in an out-of-network orthopedics clinic, created an LLC for my brand and met some amazing people and clinicians along the way.

I learned a ton about rehabilitation and fitness as well. As part of one of my biggest projects I have ever done in my life as well as for the Brookbush Institute, I authored a 42-page review of the adaptations that occur in the body from long-term high-velocity training (think plyometrics like jumping or intense activities like sprinting). Fascinating how our bodies just….do. They get it done.

I also began to become fascinated with blood flow occlusion training and its influence on our body with respect to increasing muscle mass, systematically reading all the research that has ever been published that I can get my hands on. I’m over 100 papers (and notes) in, and still have lots more to do. In short, blood flow occlusion training is cutting off some blood flow to create a pooling effect in your limbs. This pooling effect creates a stimulus in and of itself to maintain your muscle mass. This can have huge ramifications for rehabilitation after operations when you can’t move your arm or leg because of a cast or precautions from your physician. Now because your blood flow is restricted, new energy substrates (think sugar) cannot reach the muscle and so when movement (exercise) is added, you can exercise at a much lower intensity to improve your muscle mass than without blood flow occlusion. That’s the long and short of it, but I will be posting much more about it in future posts!

I’ll get it out for anyone whose reading right away – I live and breathe health and human performance. My brand, “The Human Performance Mechanic,” embodies who I envision myself as in the fitness and rehabilitation industries. Taken from my biography page:

“I’m fascinated by the human body, its unlimited potential, and its amazing ability to recover from injury. The human body is like a machine. Machines are most efficient and effective when they are in balance. When a machine is out of balance, it takes a skilled mechanic to diagnose the imbalance and provide the remedy. As a physical therapist, I see myself as a “human performance mechanic.” My goal is to keep my patients in perfect balance, have the skills to recognize asymmetries and help my patients enjoy the benefits of pain-free movement.”

Traditionally, “imbalances” and “remedys” provided in physical therapy are addressed with manual therapy. As taught in school as recently as last fall (2016), manual therapy can elicit tissue-specific effects which can include reducing the influence of adhesions, which to those unfamiliar, are supposedly areas in your muscles that become stuck together –either between the muscle and its fascial covering (which is like a sheath that has tons of complex functions, but in this case, is important in allowing movement of the muscles by allowing it to glide between surfaces–ie other muscles), the fascial covering and the skin, or any other type of combinations. In essence, I was taught that my hands could influence the relationship between the underlying tissues by working out these adhesions.

Taking a step back for a minute, I want to fill everyone in on why I actually got into physical therapy. I worked as an aide at a very upscale physical therapy clinic in Cos Cob, Connecticut for two years. It was there that I realized I could merge my love for fitness with my desire to help others. As someone who was always interested in fitness, I couldn’t believe how the physical therapists were able to alleviate someone’s shoulder pain within an hour session or help someone walk more efficiently and with less pain by releasing their hip flexor muscles. I was hooked. I thought that my hands could help heal people from their injuries the same way that the physical therapists who I worked for used their hands to almost instantly reduce someone’s sense of pain and discomfort. Manual therapy was my calling. Nothing was going to get in my way.

Fast forward to 2014-2016 at Columbia University. Anyone that asked me what my career ambitions were would hear two phrases – “Orthopedic Clinical Specialist/ Certified Orthopedic Manual Physical Therapist.” To me, those seemed like the pillar of orthopedic manual medicine. The titular titles I would earn after years of healing patients using my hands!

As a soon-to-be new graduate in late 2016, I felt that I should start to become more invested in networking and other adult-like endeavors. I decided that I would begin to put myself out there on Facebook to try to hone my skills and develop my craft. In particular, establishing a firmer foundation of my thoughts and beliefs as a future “Orthopedic Clinical Specialist” who specializes in “healing” and “manual therapy.” What better way to challenge my own beliefs than by interacting with other clinicians of various experiences and expertise? This was how I was going to learn more orthopedic manual medicine techniques! I imagined breaking them out during new patient evaluations to make them feel better instantaneously. The reactions I’d get from anyone who’d saw me. My hands were after all, novice, but eager to learn.

2017- Crashing. My belief system on manual medicine. The foundation for my profession. The reason why I chose physical therapy in the first place. Crashed.

Facebook has taught me one very important lesson. If you aren’t ever challenging … Read the rest